Pancreatic Cancer

Pancreatic Cancer Care at BMC

In a highly supportive and collaborative environment, pancreatic cancer physicians who are nationally recognized leaders in the care of patients with all stages of pancreatic cancer provide the most advanced, coordinated, and comprehensive medical care available—treatment that is effective and innovative in curing and controlling cancer and managing its impact on quality of life.

At BMC, diagnosis and treatment of patients with pancreatic cancer combines the resources of a multidisciplinary clinical center dedicated to personal, patient-focused care with the state-of-the-art expertise and technological advances of a major teaching hospital. 

What Is Pancreatic Cancer?

Pancreatic cancer is caused by the abnormal growth of cells in the pancreas.

The pancreas is located deep inside the abdomen behind the stomach in an area called the retroperitoneum and is surrounded by the liver, spleen, small intestine, and other organs.

There are two types of glands in the pancreas: exocrine glands and endocrine glands. Exocrine glands produce pancreatic enzymes that help to digest proteins and starches. These enzymes are secreted into the pancreatic duct and empty into the first part of the small intestine, called the duodenum, when eating.

Endocrine glands (found in clusters called islets) produce insulin and other regulatory hormones. These hormones circulate through the body via the bloodstream and keep various systems in check. For example, insulin helps regulate blood sugar levels.

Pancreatic tumors can be benign (noncancerous) or malignant (cancerous). Benign tumors are generally not life threatening and can often be removed. Malignant tumors, on the other hand, can be life threatening, as they sometimes invade surrounding tissues and organs and can spread to distant sites in the body.

Pancreatic cancers are divided by location. Proximal pancreatic cancers are cancers that develop in the uncinate process and head of the pancreas. Distal pancreatic cancers are cancers that develop in the body and tail of the pancreas.

Pancreatic cancers can develop in both exocrine and endocrine cells. Exocrine tumors are more common than endocrine tumors (also referred to as islet cell tumors or neuroendocrine tumors).

Symptoms of Pancreatic Cancer

Many early-stage pancreatic cancers do not cause symptoms, with symptoms only developing with progression. Common symptoms include:

• Yellow skin and eyes, dark urine, and pale stools (jaundice)
• Pain in the upper abdomen
• Chronic pain the middle part of the back
• Nausea and vomiting
• Stools that float in the toilet
• Loss of appetite or feeling full
• Unintentional weight loss
• Weakness and fatigue

Many of these symptoms can be caused by health problems other than pancreatic cancer. Individuals experiencing any of these symptoms should see their physician.

Causes of Pancreatic Cancer

Although the exact causes of pancreatic cancer remain unknown, certain risk factors connected to the disease have been identified:

• Tobacco use: Smoking tobacco is a key risk factor for developing pancreatic cancer. Smokers are at twice the risk of developing the disease as nonsmokers (American Cancer Society 2015a).
• Age and sex: The risk of developing pancreatic cancer increases with age, and the disease is more prominent in men versus women.
• Race: Pancreatic cancer occurs more frequently in African Americans than Caucasians, although the reasons for this are not completely understood.
• Family history and genetic mutations: One in 10 cases of pancreatic cancer are considered familial and are thought to be the result of genetic mutations (American Cancer Society 2015a). Genetic testing can detect these mutations in some cases.
• Obesity: The risk of developing pancreatic cancer is approximately 20% higher in people who are overweight or obese (American Cancer Society 2015b).
• Diabetes: Type 2 diabetes is associated with pancreatic cancer, and while the association is not clear, it may increase a person's risk of developing the disease.
• Pancreatitis and cirrhosis: The risk of developing pancreatic cancer is higher in people who have chronic pancreatitis (inflammation of the pancreas) and cirrhosis (scarring of the liver due to inflammation).

Risk factors currently under study include diet (particularly a diet high in animal fat) and alcohol consumption (American Cancer Society 2015a; National Cancer Institute 2010)

Pancreatic Cancer Imaging Tests and Procedures

Pancreatic cancer can be difficult to diagnose early, as symptoms frequently do not develop until the later stages of the disease. Patients who are experiencing any of the symptoms of pancreatic cancer should see their physician, who will perform a series of diagnostic exams and tests. The results of these exams and tests will also help the patient and his or her physician decide the best treatment options.

• Computed Tomography (CT) Scan
• Magnetic Resonance Imaging (MRI)
• Ultrasound
• Positron Emission Tomography (PET) scan
• Endoscopic Retrograde Cholangiopancreatography (ERCP)
• Endoscopy
• Blood tests

Stages of Pancreatic Cancer

Staging is used to determine the extent of the cancer. The most common system used to stage pancreatic cancer is the American Joint Committee on Cancer’s TNM system. The TNM system takes into account the size of the primary tumor (T), whether cancer is present in nearby lymph nodes (N), and whether the cancer has metastasized (spread) to other organs or tissues in the body (M). View TNM staging for pancreatic cancer here.

The three categories are combined to determine the overall stage of the cancer. This is called stage grouping.

• Stage I: The cancer is only present in the pancreas.
• Stage II: The cancer has invaded nearby tissues but has not invaded nearby blood vessels. The cancer may have spread to the lymph nodes.
• Stage III: The cancer has invaded nearby blood vessels.
• Stage IV: The cancer has spread to other organs in the body.

(National Cancer Institute 2010)

The grade of the cancer—how the cells appear under a microscope—also plays an important role in determining the extent of the cancer. Cancers are graded on a scale of G1 (the cells appear relatively normal) to G3 (or G4) (the cells appear very abnormal).

For treatment purposes, physicians may group pancreatic cancers into the following four categories:

• Resectable: The entire cancer can be surgically removed.
• Borderline resectable: Surgeons may be able to remove the entire cancer, even though it may have spread to nearby blood vessels. Sometimes a trial of chemotherapy is performed to try to shrink the tumor prior to surgery.
• Locally advanced (unresectable): The cancer is still local, but it cannot be entirely removed.
• Metastatic: The cancer has spread to distant sites in the body.
  (American Cancer Society 2015a)

Patients are encouraged to discuss cancer staging and treatment options with their physicians.

Gastroenterology and Hepatobiliary Tumor Board at BMC

The results of the diagnostic tests are discussed at the Gastroenterology/Hepatobiliary Tumor Board. During this weekly meeting, the entire multidisciplinary team comes together to discuss new cases and develop individualized treatment plans for each patient.

How Is Pancreatic Cancer Treated?

At present, pancreatic cancer is potentially curable only in its early stages. The best treatment option(s) depends on several factors, including the location of the tumor(s), whether the cancer has spread, and the patient’s age and general health.

Surgery

Surgery is currently the most effective treatment for pancreatic cancer. The two types of surgery used to treat pancreatic cancer are potentially curative surgery and palliative surgery. Potentially curative surgery is performed if it appears the cancer can be removed entirely. If the cancer has spread too far to be completely removed, patients may be treated with palliative surgery. Rather than try to cure the cancer, the goals of palliative surgery are to relieve symptoms and prevent problems caused by the cancer, such as the cancer blocking the bile ducts or the intestine.

Potentially Curative Surgery

The type of operation performed depends on where the cancer is located within the pancreas. For cancers in the uncinated process, head, and neck, a Whipple operation is performed. The Whipple procedure (pancreatoduodenectomy) removes part of the pancreas, the first portion of the small intestine (duodenum), the gallbladder, and part of the bile duct, as well as several nearby lymph nodes. In some cases, a small portion of the stomach may also be removed. For cancers located in the body or tail of the pancreas, more often a distal pancreatectomy is performed. In this operation, part of the pancreas is removed along with the spleen and the surrounding lymph nodes.

After surgery, patients may require medication to aid pancreatic function, such as digestive enzymes and/or insulin.

Potentially curative surgery, such as the Whipple procedure, is only performed if the cancer can be entirely removed. Removing only part of the cancer does not help the patient live longer (American Cancer Society 2015a). In some cases, surgeons may begin potentially curative surgery, only to discover the cancer is too widespread to be removed entirely. In these instances, the procedure may be stopped, or the surgeon may perform palliative surgery.

Palliative Surgery

For many patients, potentially curative surgery is not an option because the cancer is already too widespread to operate on when it is discovered. For these patients, palliative surgery may be an option. Palliative surgery is meant to treat the symptoms of the cancer and prevent problems that may potentially arise as a result of the cancer.

One problem palliative surgery may be able to treat is blockage of the bile duct. Having a blocked bile duct can not only be painful, it can also interfere with digestion and cause jaundice.

The two main options to relieve blockage are stent placement and bypass surgery.

Endoscopic Stent Placement

Stent placement is the most common procedure used to relieve blockage in the bile ducts. For this less invasive procedure, the gastroenterologist uses an endoscope to place small plastic or metal stents into the duct to relieve blockage. Larger stents can be used to relieve intestinal blockage.

Stents are not a permanent solution to blockage. Over time, the stents may become clogged and need to be replaced.

Operative Biliary and Intestinal Bypass

Instead of bile flowing from the common bile duct through the pancreas, bypass surgery redirects the flow of bile from the common bile duct into the small intestine. Additionally, if the duodenum or stomach is blocked by the tumor, a loop of intestine can be sewn to the stomach further up to allow food to be more easily digested.

The recovery time for bypass surgery is longer than for stent placement surgery, but this type of surgery offers longer-term relief.

Palliative Care

Patients receive palliative care to control pain and other symptoms caused by the cancer and to relieve the side effects of treatment.

There are several methods of pain control, including pain medicines, nerve blocks (a procedure in which alcohol is used to block pain), and complementary therapies (such as massage or acupuncture).

Palliative surgery, such as stent placement or bypass surgery, may also be used to relieve bile duct blockage and the symptoms it may cause.

Pancreatic Cancer Clinical Trials

BMC offers a number of clinical trials specifically for pancreatic cancer patients. Promising new techniques in the diagnosis, treatment, and care of patients with cancer are tested in these studies. The number and types of clinical trials available are constantly changing. View an up-to-date list of ongoing trials here. Those interested in participating in any clinical trials at BMC should speak with their physician.